Provider Demographics
NPI:1003289612
Name:BOSLOOPER, KATIE LYNNE STYKE (PA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNNE STYKE
Last Name:BOSLOOPER
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNNE
Other - Last Name:BOSLOOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:1420 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4279
Practice Address - Country:US
Practice Address - Phone:423-787-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017697Medicaid
TN103I971392Medicare PIN